Nearly every state’s legislature will begin their 2013 session this month. So January is the appropriate month to offer my five point agenda for nursing home reform. My hope is that state nursing home reform groups and individuals concerned with nursing home problems will lobby their legislators about these matters. My belief is that these five points can, at a reasonable cost to taxpayers and to nursing homes, help improve the quality of the care provided to residents.

Suggestion #1: Have each state mandate an INCREASE in the percentage of inspections (more frequently known as “surveys’) that MUST take place outside of regular business hours on weekdays. This standard should apply to both annual inspections (inspections the state conducts approximately once each year at all licensed nursing homes) as well as to surprise inspections (these are inspections that take place in response to complaints the state receives about a particular nursing home.

In many states at least 10% of nursing home inspections must begin at night or on the weekend. That means that 90% of inspections are likely done during 23% of time that accounts for regular weekday business hours. I believe that if state law would mandate a minimum of 25% – 33% of inspections begin on weekends and during hours when administrators are not normally at work the inspectors would get a more accurate view of the low quality of care that goes on in nursing homes on weekends, 2nd and 3rd shift and on holidays — the times when administrators are rarely on the job. As a family member of a nursing home resident, it was “after hours” that my mother experienced the worst neglect by her caregivers. These are the hours when the staffing levels are usually at their lowest and when management isn’t present to see for themselves what’s going on.

Inspections that take place during weekday first shift hours get a skewed picture of the care being offered. When nursing home owners and management get the message that the state CAN and WILL be showing up UNexpectedly more often, then I believe we’ll see improved staffing levels on second and third shift and on weekends and holidays.

Suggestion #2: Require management personnel to work staggered shits ALL THE TIME, not just when state inspectors are in their building. In large facilities that have an Assistant Administrator (or equivalent position), the state should mandate that the Administrator and their assistant must not be allowed to work identical shifts. In fact, I believe the state should require that the shifts for management can not overlap more than four hours per day (Example: Administrator works 8:00am – 4:30pm, while the Assistant Administrator is scheduled to work 12:30pm – 9:00pm).

The majority of nursing homes are too small to be able to afford an Assistant Administrator. Yet even these facilities MUST have a full-time Director of Nursing on staff. In these nursing homes the same “staggered shifts” rule should be in place for the Administrator and Director of Nursing.

Why suggest this legislative mandate? For much of the same reason that I made my first suggestion: after management is out of the building the quality of care given often suffers. As the cliche goes, “When the cat is away, the mouse will play!” And “play” they often do (e.g., taking excessive smoke breaks, ignoring call lights, talking on their personal cell phone instead of checking on or responding to their residents). One third shift nursing staff member at an Indiana facility where my mother lived admitted to me that she “preferred” to work overnight so “the big shots” couldn’t get in her way of doing her job the way she wanted to do it. Scary! One of CNAs who worked with this individual on third shift shared with me that this nurse took an average of seven (7) smoke breaks, OFF THE UNIT, per hour! This clearly wouldn’t be allowed by either the state or sane nursing home management — but how could the state or management know this was problem existed if they aren’t in the building at night? Residents with dementia likely aren’t capable of reporting such problems. Family members can’t stay with their loved one 24’7 non-stop to monitor this. Placement of a “Granny Cam” inside the room is incapable of documenting problems that take place outside of the resident’s rooms (as in documenting a lack of staffing at the nurse’s station caused by staff taking an excessive number of smoke breaks).

If it is impossible to have management in the building 24/7, then the state should mandate their presence a minimum of 12 hours per day on non-holiday weekdays and 4 hours (or more) per day on holidays and weekends.

Suggestion #3: When the state shows up for an any type of inspection (annual or in response to a complaint) the inspectors (a/k/a “surveyors”) should IMMEDIATELY seize payroll data to (before it can be altered) to verify staffing levels for the 14 continuous days immediately prior to the inspection. With this information in hand, inspectors should have the legal authority to insist that while they are in the building that the staffing level can NOT exceed the average staffing level for the previous 14 days.

Why would I suggest this issue requires a legislative intervention? Because calling in off-duty nursing staff during an inspection or even bring in temporary employees is one of the biggest (and most deceptive) things nursing home management does to make it appear that resident needs are being taken care of in a timely and appropriate manner — when the reality is that they aren’t being responded to in either a timely and/or appropriate manner when the state inspectors are not around. “Putting on a show” for state inspectors should be against the law!Inspectors should see and judge the quality of care based on the REALITY of ACTUAL staffing levels.

Suggestion #4: Pass legislation that prohibits nursing homes from either outright banning or limiting visits of residents by their family and friends. Once nursing home staff identify a resident’s family member(s) or friend(s) as a “trouble maker” (e.g., that we really have the courage to report their facility to the state, as is our LEGAL RIGHT AND MORAL RESPONSIBILITY TO DO) then you can count on the facility to begin setting traps (coming up with schemes) to make it look like we are the bad guy), thus justifying prohibiting (or at least limiting) visits. Some facilities have even limited visits from family and friends from taking place on the unit where the resident resides — allowing, for instance, visits to only take place in the lobby. This way family and friends can’t observe the substandard care the resident is receiving, thus preventing them from being able to observe (and thus report to the state) problems with care.

Attempts to prevent family and friends from visiting nursing home residents (when no harm is being caused to the resident as the result of the visit and when the resident wants to receive visits from such individuals) is clearly a violation of nursing home resident’s civil rights! We activists must get through to these corrupt nursing home owners and managers that their facility is the HOME of the resident and therefore the SAME rights of visitation residents had at their house, apartment on condo apply inside the nursing home facility! Strongly worded legislation is clearly the only hope we have to prevent nursing homes from taking their residents hostage!

Suggestion #5: We need legislation that will mandate increased fines against nursing homes that are found guilty of abusing resident’s rights, especially with regard to forcing residents to move to another facility. Many nursing home residents find themselves being forced out of their facility as retaliation against the resident or their family for sticking up for their rights. This type of abuse of resident’s rights must stop! It is truly a twisted, dysfunctional way of thinking when a nursing home’s only way of handling it’s problems is to punish their residents (or the resident’s family) by forcing the resident to leave their facility. How many residents must suffer “eviction” before a facility is finally forced to look inside itself and make the changes needed to resolve their real problems?

How can you help to make these five changes happen within the state where you reside? Contacting your state legislators would be a good start. Also request the support of your local or state Long-Term Care Ombudsman to help promote this reform agenda. If your area or state doesn’t have a nursing home reform organization then start one! I’ll be glad to help you start and promote such an organization.

I believe that together we CAN make meaningful, important and positive changes take place within the nursing home industry. While the industry clearly has the big bucks to spend on maintaining the status quo, we have more than enough individuals on our side to make change HAPPEN!

The text that I’m including in this post — blue, italicized text — is compiled from the comments of various nurses who visit this blog. By editing the comments of several nurses together and leaving out names of facilities (and other intimate details) I hope to protect contributors from retaliation by the nursing homes where they are employed. One thing is for certain: telling the truth (as these nurses have done) about problems in nursing homes is a one way ticket to unemployment. So protecting the identity of all nursing home staff who contact me is a high priority for me.

What nurses working in the nursing home industry have shared…

Nursing in a nursing home setting is not for the light hearted. I recently became a nurse. These days nursing can be a very sad profession to work in. While I frequently think about quitting, what keeps me going is the love I have for my residents. I truly enjoy the little bit of time I get to spend with these precious individuals.

I’m working for one of the all-powerful for-profit nursing home chains. In spite of the current economic hardships they manage to flourish financially. “How?” you may ask? One way is that they bring in headhunters to fire every employee they can — holdovers from previous owners. Then they bring in their own people to take care of the residents. These people are very business minded, but not very caring. They are more concerned about the (financial) bottom line than about providing quality care for their residents.

Meanwhile residents suffer. No friendly faces (with the revolving door employment situation). No one who knows how to make their tea or who has been around long enough to really know their personal preferences or interests. No one to position them just right so their arthritis doesn’t hurt while they are watching TV.

Further, these corporate suits come in and decrease staffing levels that were inadequate to begin with! In my facility they have one person over laundry, housekeeping and maintenance — eliminating two positions. This means that not enough staff are available to keep up the building. Rooms are dirtier when there is only one housekeeper for the whole building. Residents go without clean clothes when they have an accident. The laundry staff is lucky to get all the linens done and delivered for 200 residents with only two laundry aides, let alone doing resident’s laundry in a timely manner.

Nursing home management often insists on changing resident’s doctors, professionals who have been in place for years. These doctors know the residents and their medical history. Nursing homes often hire very young nurses and place them in positions of power. New doctors and new nurses go along with the big corporation’s rules, placing corporate profits above compassionate care.

Then the nursing staff-to-resident ratio (for both nurses and CAN’s) in our state is a real problem. The nursing staff can’t keep up! Meanwhile this company is making money hand-over-fist, buying the administrative staff “iphones” and redecorating the facility. High tech gadgests and designer décor should never be more important than maintaining appropriate staffing levels! Cutting back the time that the nursing staff can spend with our residents is not good for resident care! Priorities, please!

With such horribly inadequate staffing levels, resident care truly suffers. Taking care of that many needs of the residents, including knowing their medical diagnoses, allergies, keeping track of doctor appointments, their quirks and mannerisms, and their baseline behavior so I can tell if something is not right – all of these things along with doing the paperwork required by the state and facility – truly make for a heavy workload for the nursing staff.

An answer of “I don’t know, you see I didn’t get to spend much time with our residents because we are so busy due to short staffing” isn’t going to make a good impression in a court of law.

When the “priority” in running a nursing home is anything other than resident care, obviously nursing home residents suffer. The priority of maximizing financial profit is NOT compatible with the priority of providing quality care. Sadly, especially in for-profit facilities these days, the quality of care is bad to downright pathetic! Truly “bean counters”need to be run out of the nursing home industry!

The dedicated nurses, CNA’s and other nusing home staff also suffer when greed trumps care. Understaffing, clearly a problem rooted in corporate greed, adds to stress for those caregivers who want to provide quality care but aren’t given enough time to do their job right.

To the CNAs and other nursing staff “working” at a nuring home located in a small town in southern Illinois…

“FCOL!!! U been seen txting while on the clock (at and/or near the nurse’s station). U are pd. to care for yur residents, not play w/yur cell phones while on the job. Pls work on being more responsive 2 the residents entrusted to yur care! U certainly wouldn’t want the state inspectors 2 find U txting while at work, would U? Does yur facility need a surprise inspection to get this problem fixed? When a resident has GGP, s/he shouldn’t have 2 wait on you BC U R playing w/your phone! Yur facility has a great reputation, too bad your job performance doesn’t prove 2 b so hot! Now then: get B2W!”

Here’s a translation of the above text message…

“For crying out loud!!! You’ve been seen sending and receiving text messages while on the clock (at and/or near the nurse’s station). You are being paid to care for yur residents, not play with your cell phones while on the job. Please work on being more responsive to the residents entrusted to your care! You certainly wouldn’t want the state inspectors to find you playing with your cell phone while at work, would you? Does yur facility need a surprise inspection to get this problem fixed? When a resident has to got to go pee, s/he shouldn’t have to wait on you because you’re playing w/your phone! Yur facility has a great reputation, too bad your job performance doesn’t prove to be so hot! Now then: get back to work!”

When a nursing home resident needs assistance of any sort, nursing staff should never allow the use of their cell phone, taking excessive smoking breaks or gossiping with co-workers to slow their response time. Please remember that you are paid to CARE for your residents — and to refuse to do so clearly constitutes neglect!

My thanks to “J”, a certified nurses aide (CNA) who works at a nursing home in central Indiana, for sharing the following thoughts about her experience as it relates to the problem of understaffing and other issues of concern (like a lack of adequate training for CNAs, etc.). Her identity is not being revealed in order to protect her from retaliation from management (although if “Stuart R.” reads this, he might be paranoid enough to fire every CNA who works in his chain of nursing homes who’s first name starts with “J”. Wait, what if “J” were actually a male?) 🙂

I’m a new CNA. I don’t feel that I received adequate training in school or upon hiring. I’m feeling shattered and overwhelmed. I’ve just landed my first-ever CNA job (at an Indiana nursing home). I found out during training that I love the residents and the very nature of this work. My teacher predicted I would fall in love. And I did.

I love my residents. I understand they probably ran circles around me when they were my age. Unlike them, I don’t know how to make apple pie from scratch, stay married to the same person for 50 years, raise eight cloth-diapered children, harvest 10 acres each of corn and wheat, or milk six cows and collect the eggs from 2 dozen hens before sunrise and then butcher, pluck, and fry one of these aforementioned hens for Sunday dinner! I’m fond of them, I care about them and I respect them.

My facility pays exceptionally well (to make up for being chronically understaffed, perhaps?). I’m inexperienced and slow and flying by the seat of my pants. I’m honestly doing the best I can and still I don’t feel I’m doing right by any of them and I don’t know what to do about it. My assignment for the past two shifts has been 29 residents, the majority of whom I haven’t had time to become familiar with. This boils down to roughly 15 minutes of individual care per resident spread out over eight hours. Two minutes per resident is shaved off due to reasons that could have been avoided by a little forethought on the part of those in authority. Stupid reasons, such as having to chase down rubber gloves, wipes, clean linens and briefs, or read 20 charts because I’m in charge of the health and safety of people I know nothing about and any uninformed decision or action on my part has the potential to kill someone.

A few of the 29 residents I care for are pretty self-sufficient, while the rest of them require and DESERVE way more than the remaining 13 minutes of hands-on care. These are people’s mothers and fathers. They could be my parents. The quality of care I have time to give each resident is inadequate, and certainly far below that which I would expect if they were my own parents. I feel like they’re being neglected. Neglected by me, despite that I don’t have an idle moment and usually end up working off the clock.

When I finally fall asleep after I get home, I have nightmares. I don’t believe that even the most experienced and proficient of aides can provide *adequate* care to that many residents singlehandedly. I’m probably going to get fired for not charting. Because I can’t bring myself to ignore a call light and humiliate one of my beloved residents into soiling herself so that I can go make a note that someone else “eliminated” and how much and whether or not it was in a brief or in the toilet, while someone is begging *right now* to be taken to the toilet to eliminate like the adult that she is.

So there’s this nurse who is counted among THE PEOPLE WHO ARE OFFICIALLY CARING FOR YOUR MOM OR DAD. Because she’s there at the same time as I am, the facility gets to count her as someone who is providing hands-on care. Except all she does is administer medications. She’s “above” doing what she can to make sure your mother isn’t having her skin digested by the enzymes in her diarrhea. She can see that I’m already up to my elbows in seven different cases of diarrhea, yet she’ll sit and chitchat with the other nurse about what’s on sale at K-Mart and still see fit to remind me about all these other call lights that are on, rather than step up herself and care for a resident who is suffering from the caustic germs that’s eating the skin off his nether regions.

I just wanted to propose the possibility that for every aide you encounter who seems jaded and apathetic, there’s another one who wishes she had a button to stop time and make sure absolutely everyone’s every need is met, so that she could go home and rest easy feeling that her best was good enough by her own standards. I don’t know who to hate more, myself for not knowing how not to fail my residents, or the greedy powers that be at the facility for failing all of us. There’s a very high turnover rate for CNAs. I had to become one to understand why.

Please know that it breaks my heart to see you or your mom or your dad suffer and I will do everything in my power to prevent that, but that my power is very, very limited. Please understand that I have to feed my kids and this is the only way I know how to do it. Please keep in mind that the people with the least authority and power are most likely the ones who are the most emotionally invested in your mom’s or dad’s happiness and well-being.

Anyway, I just wanted you to know how much a lot of us care and how much some of us are up against.

May God richly bless every loving, hard working CNA like “J”! May God give them the strength (physically and otherwise) to provide excellent care like “J” obviously provides to her residents. May God provide nurses (unlike the one referred to in “J”‘s comments) who will conscientiously lend a hand to her hard working CNAs (instead of talking on their cell phones at work, or talking about the latest sale at K-Mart, etc.).

My opinion is that, in a more perfect (nursing home) world, CNAs would be paid better, be allowed to be involved in the care planning of their residents (something few facilities currently allow) and be treated with much more respect by the nurses they work with.

I can’t speak for foreign countries, but here in the United States every part of every state has someone (sometimes several persons) to help nuring home residents and concerned loved ones to assist when concerns about nursing home care (or lack of care) arrise. These helpful individuals, known as long-term care ombudsmen, are often times underpaid and overworked. Some ombudsmen are unpaid volunteers who are supervised by paid ombudsmen. Their service is FREE to nursing home residents, family members and concerned friends of residents.

When is it appropriate to contact an ombudsman? In a non-emergency situation, it is best to contact them after the concerned party has been unable to resolve their concerns with nursing home management.

If you feel you have an urgent or emergency situation involving the safety or welfare of a nursing home resident, then immediately contacting an ombudsman (without trying to resolve matters with the facility) may be entirely appropriate. However when you have an emergency situation and time is of the essence, the best place to turn for help is the state agency responsible for regulating nursing homes within their jurisdictions (in Indiana the agency is the state Board of Health, within Kentucky it is the Office of the Inspector General — all nursing homes must provide those who ask with contact information for the state agency responsible for regulating them. Nursing homes must also provide the phone number for the nearest long-term care ombudsman. Most states require nursing homes post this information in a prominent place, such as near the main entrance of a facility or at/near a nurse’s station. The bottom line is that if you ask facility staff for contact information for the ombudsman or state nursing home regulatory agency, they MUST provide you with that information, which should include a phone number.

In many states it is also entirely appropriate to contact the local office of Adult Protective Services when you feel the safety, rights or welfare of a nursing home resident is threatened. Call your local police or sheriff’s department to find the number for the Adult Protective Services office that serves your area.

My experience (and that of many other loved ones of nursing home residents) is that nursing home staff and management will often feel threatened and become overtly hostile when they become aware that an ombudsman, state regulartory agency or an Adult Protective Services office has been contacted about problems at their facility. Big deal! If they (e.g., nursing home staff and managment) are doing their job (let alone doing it correctly), then they have NO reason to fear the state’s intervention! Please don’t allow nursing home staff or management to intimidate you into silence! You have a legal right and a moral responsibility to request state intervention on behalf of a nursing home resident!

To find contact information for the Long-Term Care Ombudsman in your corner of the United States, please visit the website of the National Citizen’s Coalition for Nursing Home Reform (www.nccnhr.org). On the left side of every major page of their website you’ll find a button with the words “Locate An Ombudsman”. Click on that button to find the information you need. In addition to ombudsmen, you’ll also find listings for each state’s nursing home regulatory agency and other agencies that respond to concerns related to nursing home care.

I need to point out that while ombudsmen are available to investigate concerns and offer advice, they do not have the legal authority to force nursing homes to do anything. Only the state agency entrusted with long-term care facility oversight has such power. Adult Protective Services employees also have legal authority that ombudsmen do not have. At the same time, ombudsmen will be able to render a responsible opinion regarding when it is appropriate to contact the state, in case you aren’t sure if this the right option to pursue. Their wisdom and experience is an invaluable tool in protecting your loved one.

I am frequently shocked by accounts I hear about how badly UNDERstaffing that exists in many nursing homes. I’m a family member, so it is easy for nursing home owners and management to dismiss my concerns (and those of other family members) by claiming our expectations are too high. Management acts as if we family members are too dumb to realize that their facility does have “adequate staffing” — yet we often witness our loved one (and other residents as well) not having their needs met, because the resident-to-staff ratio is woefully INadequate.

So please don’t take my word about the evil of nursing home UNDERstaffing. Instead, please take the word of a newly-hired Certified Nurses Aide-In-Training. Her insider account of the facility where she works should make you angry and to realize that ALL of us have a responsibility to work to bring about ethical and sane staffing standards.

This visitor to our blog wrote the following, her name and location are kept confidential for the purposes of this account…

“I just started working at a nursing home as Certified Nurses Aide “in training” –read: no formal training.

On my own on a recent night I was the only aide working and was responsible for the care of 45 residents. The only other nursing staff member on duty in this unit was the nurse (who couldn’t be bothered about resident’s needs).

I ran all night, couldn’t keep up, just wanted to keep the residents clean and comfortable. So many! 3/4 of the residents are incontinent, 1/2 have motion sensors on them due to fall risk. 1/3 needed some extra compassion, and more every night with signs of infection. I cry every time I walk out. I get yelled at and shunned because I take too long, when all they want is a drink, a clean blanket, and maybe even a hug. I thought that was what anyone needed, but apparently, only if they can get it themselves. I have NO TRAINING and I was ALONE for an eight hour overnight shift. In addition to direct resident care, I also have to wash wheelchairs and chart those bowel movements.

Again, I have NO formal training yet, aside from the training I have given myself through research and hands on care. I followed a couple of aides around for a few days, only one of them was actually certified.

I have spent a total of four days in training for “corporate understanding”, which involves travelling to another town to hear about how great this company is, then going home to work a night shift.

I had two nights of “supervised” work, which meant that depending on who I was supervised by, I was either on my own or frantically looking for someone that knew what to do. However, I have been walking around in the same scrubs that certified aides wear, and when a resident sees me, they think help has arrived. I quickly learned to give up on finding someone else (more experienced) and just help them any way I can.

I spent the night trying to get her to help me with a resident that was screaming and pulling at her catheter, only to find that the nurses “help” was to go into the room and tell the resident, “Shame on you!”

I literally ran up and down the halls, trying to help everyone, trying in earnest to turn everyone every two hours, change everyone when soiled, strip and make beds with people still in them, lift and transfer residents alone on my own and dress them all starting at 3:30am to be gotten out of bed no later than 5:00am.

I tried to inform the nurse about a resident who had recently had a medication change and could no longer transport themselves to bathroom. The resident was vomiting and had diarrea. The nurse ordered me to “stop taking so long in there”.

A resident on Hospice needed a bed bath, I gave it, hour later, thought he may have been dying since he was panting and grunting. I went in to check on him and he took my hand and wouldn’t let go.. The nurse’s response, “That’s because you messed with him”.

This is all tip of iceberg. I thought I wanted to be a nurse, I have a good head for medicine, and a big heart. Now I think that that may be why I cannot go into this field. I will fight tooth and nail before admitting my mother to a nursing home. I know there are times it is needed, but people need it so they can get BETTER care, not so they can be institutionalized, ignored and treated like a piece of meat.

These resodemts don’t need much, but what they need is so important! Why couldn’t management hire two more nurses aids on third shift? I only get minimum wage for crying out loud!

May God richly bless our friend Bernie Vonderheide, founder of Kentuckians for Nursing Home Reform, for his hard work on behalf of creating positive changes in nursing homes within the Commonwealth of Kentucky! His commitment is truly inspiring and his organization is one that I urge all of my fellow Kentuckians to support.

Bernie shares the following words of encouragement as we start this blog…

Congratulations on starting an important educational blog.

One of the biggest problems in nursing home reform is that most people do not understand the problems unless that have been there and actually seen it. That is why education is such an important part of our mission.

We encourage everyone to share their experiences with the public through this new blog.

Looking forward to being a daily reader, and congratulations once again.

Thanks Bernie for those thoughtful words!

Allow me to remind you that while Bernie and others of us are very much public figures in the area of nursing home industry reform, we will respect your request for anonymity should you chose to share your story for publication. We will also keep your e-mail address completely confidential.

In addition to publishing your story of nursing home neglect and abuse, this blog also exists to share links to websites of interest to those of us who support reform of the nursing home industry. We will also reprint editorials and other material related to the topic of making positive changes in long-term care facilities. Links can be found under the BlogRoll section on the right side of this page.